Peterborough City Hospital

To evaluate the use of a 360-degree conjunctival graft in combination with three different biomaterials: amniotic membrane (AM), porcine small intestinal submucosa (SIS), and porcine urinary bladder acellular matrix (UBM) in dogs with extensive keratomalacia. Medical records from a single referral center were retrospectively reviewed. Dogs with extensive keratomalacia affecting at least 50% of the corneal diameter that underwent a 360-degree conjunctival graft in combination with a biomaterial (AM, SIS, UBM) were included. Nine eyes from nine dogs were included. The mean horizontal percentage of the malacic cornea was 68.4% and mean vertical percentage was 67.7%. Ulcer depth ranged from > 70% stromal (66.7%), descemetocele (22.2%), and corneal perforation (11.1%). Mean follow-up time was 153 days (range: 17-483 days). Successful corneal healing and globe retention was achieved in 8/9 eyes (88.9%). Of the preserved globes, 7/8 eyes (87.5%) were visual at the last follow-up. The use of a 360-degree conjunctival graft in combination with AM, SIS, or UBM for the treatment of melting ulcers affecting > 50% of the corneal surface resulted in excellent globe and vision retention rates. Significant and profound corneal vascularization, granulation tissue, fibrosis, and edema were noticed in most cases following the release of the 360-degree conjunctival graft, which reduced over time.

BackgroundAcute pain accounts for 60–90% of presentations to the emergency department (ED), with 20–40% of patients reporting severe pain. Current management practices, including simple analgesics, opiates and anti-inflammatory drugs, are often inadequate or slow to reach peak effect, necessitating the exploration of alternative analgesics. Ketamine, acting primarily through N-methyl-D-aspartate (NMDA) receptor antagonism, presents a promising alternative due to its rapid onset. However, its nebulised form remains underutilised in clinical practice.Aims and objectivesThis review evaluates the efficacy of nebulised ketamine in reducing pain in adult ED patients, alongside its side effect profile, optimal dosing, and potential as an alternative or adjunctive analgesic compared to other treatments.Methods and designA systematic review utilising the PRISMA guidelines was conducted. Searches were carried out in Medline, Embase, PubMed, Science Direct, google scholar and Ovid databases from 2010 to May 2024, including studies containing objective analysis of pain control with nebulised ketamine. A two-sample t-test was used to assess statistical significance. Quality assessment was performed using the CASP tool, and bias was evaluated using the ROBINS-I and ROB2 tool.ResultsOf 99 articles, 9 (5 randomised controlled trials, 3 case series and 1 case report) totalling 453 patients were included. All studies suggested improvement in pain scores with nebulised ketamine, with an average reduction of 42.5% and 70.4% over a 15 and 120-minute period respectively (p < 0.0001). Higher doses (1 mg/kg, 1.5 mg/kg) did not significantly improve pain compared to lower doses (0.7 mg/kg 0.75 mg/kg), with similar overall reductions reported across all four dosing regimens (p < 0.0003 or 0.0001). Nebulised ketamine was non-inferior to intravenous (IV) morphine, IV ketamine, nebulised dexmedetomidine, and Entonox, and had fewer side effects.ConclusionNebulised ketamine offers a viable alternative for pain management in emergency settings, providing effective analgesia with a favourable safety profile. Further multicentre trials with larger populations are recommended to confirm these findings and establish standardised dosing protocols for consideration in national guidance.

Community-based optometrists, a major provider of primary eye care in the United Kingdom, are the main source of referrals to hospital eye services. The widespread introduction of optical coherence tomography devices in community practices provides community-based optometrists with an opportunity to identify a broader range of treatable diseases. Standard referral pathways do not effectively filter unnecessary referrals, with misclassification of urgency, and erroneous diagnoses. To assess the effectiveness of a teleophthalmology referral pathway between community-based optometrists and hospital eye services for retinal diseases. To measure the accuracy of an artificial intelligence decision support system for diagnosis and referral management of retinal disease. A multicentre, superiority cluster randomised controlled trial to assess the effectiveness of a teleophthalmology referral pathway. A prospective, observational diagnostic accuracy study to measure the performance of artificial intelligence decision support system. A comprehensive economic evaluation was conducted. United Kingdom-based community optometry practices with an optical coherence tomography device and hospital eye services. Adults requiring referral for retinal disease at the opinion of the community-based optometrists. Community optometry practices were randomised 1 : 1 to standard care or teleophthalmology. Referrals sent via the teleophthalmology platform were remotely reviewed by human experts based at the corresponding hospital eye services. A referral decision was provided within 48 hours. Suitable optical coherence tomography scans were solely processed by artificial intelligence decision support system (the 'Octane' model). Cluster randomised controlled trial's primary outcome was the proportion of false-positive referrals (not required or not urgent) per arm in overall participants and in referred-only participants against an independent reference standard. Secondary outcomes included the proportion of wrong diagnosis, wrong referral urgency, false-negative referrals, safely triaged referrals for rare diseases, time from referral to consultation and treatment and cost-effectiveness of teleophthalmology. Primary outcome for the artificial intelligence study was the sensitivity and specificity of artificial intelligence referral decisions against the reference standard. Teleophthalmology significantly reduces the proportion of false-positive urgent referrals by 59% compared to standard care in referred participants. Due to the observed low event rate for false positive referrals, teleophthalmology's role for reducing false positives overall was inconclusive. No significant difference between arms for safety of referral decisions (false negatives) was found. After accounting for external factors, the time to consultation demonstrated both clinically and statistically significant benefits for the teleophthalmology arm. The time to treatment showed a clinically significant benefit. Of 396 recruited participants, the Octane artificial intelligence model processed images contributed by 204 participants (51.5%). For referral decisions, the model showed comparable sensitivity and specificity against its own preset referral rules (rule-based reference standard) (post hoc analysis), but it showed inferior sensitivity and specificity when compared to human expert assessors making these referral decisions (clinical reference standard) (primary AI analysis). The artificial intelligence model presented challenges relating to its generalisability in a real-world evaluation context. Technical limitations in optometry practices, lack of ethnicity data. Asynchronous teleophthalmology reduces the number of unnecessary urgent referrals, the main drivers of increasing hospital capacity pressures, provides more appropriate referral-to-treatment times and is more cost-effective compared to standard care. The Octane artificial intelligence model could not process images from 48.5% of study participants. Compared to hospital-based experts for referral decisions, Octane was less accurate at making routine and urgent referral decisions and of similar accuracy to community optometrists. Applied health research, human-artificial intelligence interaction and artificial intelligence clinical trial design. This trial is registered as ISRCTN18106677. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127773) and is published in full in Health Technology Assessment; Vol. 29, No. 69. See the NIHR Funding and Awards website for further award information.

The optimal management of localized diverticular perforation remains uncertain, with ongoing debate between surgical intervention and conservative antibiotic therapy. While randomized trials have addressed uncomplicated diverticulitis, evidence specific to perforated disease is limited and heterogeneous. This study aimed to evaluate the effectiveness of surgical intervention compared to antibiotic therapy in managing localized diverticular perforation in adults, focusing on key clinical outcomes including adverse events, stoma creation, mortality, and intra-abdominal abscess formation. We conducted a systematic review and meta-analysis of studies comparing surgical versus antibiotic therapy in adults with localized diverticular perforation. Major outcomes included composite adverse events, stoma creation, all-cause mortality, and intra-abdominal abscess. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed using the I² statistic. Four comparative studies (n = 12,922 patients) were included. For composite adverse outcomes, no significant pooled difference was observed (Pooled OR 3.79, 95% CI 0.36-39.56, p = 0.266; I² = 97.4%), though individual studies showed conflicting results. Surgical intervention was associated with a significantly higher risk of stoma creation compared to antibiotics (Pooled OR 16.16, 95% CI 4.11-63.63, p < 0.001; I² = 43.3%). Mortality did not differ significantly between groups (Pooled OR 3.68, 95% CI 0.28-47.99, p = 0.320; I² = 88.8%). Intra-abdominal abscess rates were also comparable (Pooled OR 3.01, 95% CI 0.53-17.07, p = 0.212; I² = 87.8%). Surgical management of localized diverticular perforation provides definitive treatment but significantly increases the risk of stoma creation. Antibiotic therapy may be effective in carefully selected patients, particularly when initiated promptly, although study findings remain inconsistent. Given the high heterogeneity across available studies, further randomized trials are needed to establish evidence-based guidance for treatment selection in this patient population.

The management of unstable Weber B ankle fractures presents significant challenges, particularly in patients with osteoporotic bone. Conventional fixation techniques often employ a lag screw to achieve compression at the fracture site. However, in osteoporotic bone, this approach may fail to provide adequate compression and may cause complications such as irritation to surrounding tendons or the distal tibiofibular syndesmosis, sometimes necessitating additional surgery for hardware removal. We describe a novel "seesaw" technique that uses a laterally applied, obliquely oriented locking plate to achieve stable fixation. After initial provisional stabilization with a K wire instead of a lag screw, the distal end of the plate is secured with locking screws. A non-locking screw is then inserted just proximal to the fracture site, serving as a fulcrum. By applying posterior pressure to the plate, a "seesaw" motion is induced, translating the distal fibular fragment anteriorly. This maneuver enables compression across the fracture site and restores anatomic alignment. Final fixation is completed with additional locking screws. Over a three-year period, this technique was employed in more than 50 patients with unstable Weber B fractures. No cases of syndesmotic instability, malalignment, or loss of reduction were observed during the rehabilitation period. This method provides a stable, reproducible alternative to standard fixation techniques and is especially advantageous in osteoporotic bone. It allows for precise anatomic reduction, sustained fracture compression, and early mobilization, potentially reducing complication rates and the need for secondary procedures.

Systemic sclerosis is an autoimmune connective tissue disease that affects multiple organ systems, leading to diverse clinical presentations. Raynaud’s phenomenon is one of the most common early manifestations, reflecting the underlying vasculopathy. In rare cases, vascular changes also involve internal organs, including the gastrointestinal tract. We present the case of a 79-year-old female who first presented in 2015 with recurrent iron-deficiency anaemia requiring multiple blood transfusions. Oesophago-gastro-duodenoscopy revealed features of “watermelon stomach,” consistent with gastric antral vascular ectasia (GAVE). She underwent multiple sessions of argon plasma coagulation to control bleeding. Seven to eight years later, she developed classical features of systemic sclerosis, including sclerodactyly, worsening Raynaud’s phenomenon, skin calcifications, and digital ulcerations. Autoimmune testing was positive for antinuclear antibodies, anti-Ro, and anti-centromere antibodies, confirming limited cutaneous systemic sclerosis. This case demonstrates the potential for GAVE to appear before other features of systemic sclerosis become clinically evident. Patients presenting with idiopathic or recurrent GAVE should be evaluated for underlying connective tissue disease, as timely recognition can influence monitoring, treatment, and long-term outcomes.

BackgroundSeizures are a common consequence of acute hemorrhagic stroke, which has a high morbidity and fatality rate. It is yet unknown how they relate to age, the National Institutes of Health Stroke Scale (NIHSS), the modified Rankin Scale (mRS), and discharge status.MethodsWe conducted a cross-sectional study of 75 patients (aged 16-92 years) with acute hemorrhagic stroke admitted to the Neuropsychiatry Department of Qena University Hospitals, a tertiary care center serving a large catchment area in Upper Egypt. Data were collected over six months, from September 2024 to February 2025. Neurological impairment was assessed using the NIHSS, and functional outcome was measured using the mRS at admission and discharge. Statistical comparisons included paired t-tests and Wilcoxon signed-rank tests. Associations between seizures, age, stroke severity, and outcomes were also analyzed.ResultsSeizures were not correlated with age. During hospitalization, a noteworthy mean improvement in NIHSS (+0.97; t = 10.70 and p < 0.0001; W = 21.50 and p < 0.0001) was noted, suggesting neurological recovery. On the other hand, mRS remained at a median 3 (t = -0.51 and p = 0.6113; W = 275 and p = 0.9173), indicating no discernible change. There was no discernible change in NIHSS or mRS among patients who were released on demand (n = 10). Ten out of the 12 in-hospital fatalities had seizures, and the majority had moderate-to-severe strokes (NIHSS ≥9; mRS ≥3). Patients with very severe strokes (NIHSS 16-17; mRS = 5) and no recovery experienced two non-seizure fatalities. Admission NIHSS (1-17) and mRS (1-5) showed a broad variety of stroke presentations and recovery trajectories.ConclusionThe baseline of stroke severity was the best indicator of a bad prognosis in acute hemorrhagic stroke, and seizure incidence was not age-dependent. Significant neurological recovery was recorded by NIHSS, but short-term functional improvement was not reflected by mRS. These results indicate that seizures are more common in fatal cases but secondary to the total load of strokes, underscoring the prognostic significance of baseline severity.

Idiopathic intracranial hypertension (IIH) and polycystic ovary syndrome (PCOS) are strongly associated with obesity in women of reproductive age. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been extensively reported to facilitate weight loss through central satiety. Emerging evidence demonstrates additional benefits of GLP-1 RAs. Exenatide exerts direct effects on choroid plexus receptors, reducing cerebrospinal fluid (CSF) secretion and intracranial pressure (ICP), and on the ovary, enhancing follicular maturation, restoring ovulation, and improving fertility outcomes in PCOS. A 29-year-old woman with PCOS was referred from gynecology for assessment of intermittent visual blurring and chronic headaches. Ophthalmic examination revealed normal monocular visual acuity of 6/5 in each eye but reduced binocular vision of 6/12, associated with double vision. She also reported a weight gain of 15 kg over eight months. Fundoscopy was unremarkable, with no optic disc swelling. IIH without papilledema (IIHWOP) was diagnosed based on magnetic resonance imaging showing an enlarged pituitary fossa, partial empty sella, and optic nerve sheath dilatation, with lumbar puncture confirming a raised opening pressure of 280 mmH₂O and normal CSF. Initial treatment with acetazolamide was discontinued due to intolerance. Exenatide was subsequently initiated, leading to early improvement in headache frequency and diplopia, independent of weight loss. Menstrual cycles, hormonal profile, and insulin resistance also improved beyond the effect of metformin alone. This case highlights the potential of exenatide to provide dual therapeutic benefits in IIH and PCOS, acting through direct receptor-mediated pathways to reduce ICP, improve headaches, and restore ovulatory cycles, and indirectly through the reduction of central obesity. Further studies are warranted to establish its role in the combined management of these conditions.

Hip and groin pain are frequent presenting complaints among elderly patients. These symptoms are most commonly related to fractures, which are usually identifiable on X-rays. Spontaneous iliopsoas tendon injury, however, is a rare and under-recognised cause of atraumatic hip or groin pain in this population. We report the case of a 90-year-old woman with a history of multiple comorbidities on long-term warfarin for atrial fibrillation who presented with dull left groin pain radiating to the lower back and marked limitation of mobility in the absence of recent trauma. On admission, the international normalised ratio (INR) was 3.98 (reference range, 2-3) and warfarin was held; haemoglobin (Hb) was 87 g/L (reference range, 115-165 g/L), which is the patient's baseline with no fall on serial checks. Examination revealed severe pain on resisted hip movement and groin tenderness, while pelvic X-rays excluded fracture. CT imaging demonstrated bulky soft tissue tracking along the left iliacus muscle extending to the lesser trochanter, consistent with spontaneous iliopsoas tendon rupture with intramuscular haematoma. Orthopaedics recommended conservative management with analgesia, mobilisation as tolerated, and inpatient rehabilitation. MRI was not pursued as it would not have altered the management. The patient remained haemodynamically stable without any drop in haemoglobin levels. This case highlights the importance of considering spontaneous iliopsoas tendon rupture in elderly patients who present with atraumatic hip or groin pain and have non-diagnostic X-rays. Timely cross-sectional imaging is often key to making the diagnosis. Early diagnosis allows appropriate conservative management and is associated with favourable functional outcomes.